The ACA made the prudent layperson standard federal law (ACEP piece). The prudent layperson standard is exactly what it sounds like: the definition of a medical emergency is that a normal person with an average knowledge of medicine thinks is an emergency -– the patient’s symptoms make it an emergency, not the final diagnosis. So severe abdominal pain that turns out to be “just” an ovarian cyst is, by definition, an emergency.

This is both obvious and good: the patient can’t tell if their severe abdominal pain is something terrible and dangerous like appendicitis or something that’s painful but not dangerous.

And once again, this is very important because we shouldn’t expect people to sit at home and worry about whether their severe pain is “just a cyst” or a ruptured appendix or an ovarian cyst causing an ovarian torsion or massive internal bleeding.

If the patient is acting like a “prudent layperson” and thinks they are having an emergency, then it is an emergency and the insurer has to cover the ER visit. Full stop.

This is really important because there is a huge overlap in symptoms between simple benign problems (ovarian cyst) and serious life threatening problems (appendicitis) -- see this fantastic paper by Maria Raven et al.

Anthem is breaking the law by denying claims based on final diagnoses in cases like this and it is terrible and people will get seriously hurt.

Tons of patients end up with final diagnoses like “acute viral bronchitis” which sound simple. Except when the patient is 80 and has CHF and COPD and it could easily be flu or pneumonia or a serious COPD or CHF exacerbation any or all of which could kill them.See my previous post with a bunch more resources on how worthless and dangerous it is to try to decrease “unnecessary” ER visits.UPDATE 2/17/18: Consumer Reports just published a piece on a patient getting denied ED coverage for severe headache that turned out to be "just" mastoiditis.

4) EDs aren't overcrowded because of low acuity patients; we are busy because of boarding -- patients we have seen & admitted in the ED and are waiting for their inpatient beds. (tons on this, here's one on how boarding-> crowding in Annals by Brent Asplin et al A conceptual model of emergency department crowding, and 2 of my blog posts 4A) here and 4B) here and 14 below)

5) And for those who suggest higher patient copays for low acuity ED visits, the famous RAND HIE, which shows that patients who have to spend more out of pocket decrease *all* care, both appropriate & inappropriate care (which isn't surprising, given Raven's study, above):RAND HIE

12) This great episode of EM Over Easy on fundamental attribution error
and
13) David Foster Wallace's This Is Water.
The basic idea: when I cut someone off in traffic, I make excuses for myself (I'm late to work, the light is changing, etc etc) but when someone cuts me off, of course I think they're just a jerk. The less I judge patients for being in the ED, the less stress I have.

15) friendly reminder that the legal definition of a medical emergency is
"a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in... placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; ...serious impairment to bodily functions; ...[or] serious dysfunction of any bodily organ or part.)"

If a regular person with no medical training thinks their symptoms are an emergency, it's an emergency and the insurer has to cover it.

My initial reactions: hmm, some of this looks like lack of Medicaid expansion, some might be from a combination of too-high premiums/insufficient subsidies/ignorance of subsidies etc on the exchanges.

But wait, "childless adults"? That sounds familiar!

"Childless adults, most uninsured under traditional Medicaid." For those who have studied health policy, it's a stimulus-response, like "chloramphenicol, grey baby" and "dental plan, Lisa needs braces."

I followed the link and noticed the normal, understated citation at the bottom of the post:

Who is Impacted by the Coverage Gap in States that Have Not Adopted the Medicaid Expansion?

This reminds me of the famous desaturation curve which appears in every airway lecture, as mandated by CMS due to Obamacare:

Note the title of the source of this familiar graph: Critical Hemoglobin Desaturation Will Occur before Return to an Unparalyzed State following 1 mg/kg Intravenous Succinylcholine.(Benumof, Dagg, Benumof. Anesthesiology. 1997 Oct;87(4):979-82.)

How often are these graphs shared without noting their expressed purpose?

July 25, 2016

As the new medical-academic year begins, I'm guessing a bunch of new interns will learn about how great FOAM is, and at the same time, get an orientation lecture on "threats to professionalism." Obviously I think there is a ton of potential benefit to using social media as a medical professional, and here are some of the ways I "maintain professionalism" (read: keep myself out of trouble).

One of my big keys is to not try to "not violate HIPAA" – that's easy and too low of a bar.
The real key is to not piss off the carpetwalkers: I don't want to have to defend myself in a meeting with Risk Management. Instead, I want to maintain a general profile I can defend to my dean and my department chair (and maybe someday to the promotion & tenure committee).

Twitter is a Giant Elevator
My big overall philosophy is that social media is like talking on an elevator. But: my mom, department chair, medical school dean, the patients' family, and a million other people are in the elevator. Obviously that doesn't mean that I'm always banal and polite. Rather, I recognize that people will see what I write and it is always tied to me.

Patient Privacy
Easy version: never talk about real patients.

Slightly tougher but still easy: if I do want to talk about real patients, I change enough of the details so that if the actual patient were to see it, the patient wouldn't recognize that it was them.

Two mistakes people make: date of service and age over 90 are HIPAA-protected PHI. The number one thing I do if I am referencing something that happened to a real patient is that I don't do it the same day (or even the same week).

I never even reference "oh look what happened on my drive to work today" so there can't be a real connection between anything I say and a real patient. And I don't share pictures from work or of patients without all of my ducks in a row (if at all).

On Anonymity
I'm not opposed to being anonymous, but I'm very much intentionally not. This is partially as a check on myself -- I know whatever I say is tied to me. A big part of it is to avoid the fear of people discovering my secret identity.

I'm not recommending anyone be anonymous on social media, but if I were, I would tell all my relevant bosses (e.g. program director, chair).
If something serious "goes down," i.e. there's some sort of scandal, and it's a total surprise and secret to everyone, I imagine that there will likely be a big sense of betrayal.

But I don't want to be anonymous, it means you are giving up a lot of the upside. I imagine the benefits are possible but a lot harder if anonymous. Because the bottom line is that there are legitimate career, academic, and potentially financial benefits to being active on social media as a medical professional.